What are the barriers to equitable maternal health in Aotearoa New Zealand?

Abstract

Background: Aotearoa New Zealand has a socialised health care system with free at point of delivery maternity care. Care is also uniquely structured, led by autonomous, principally community based, lead maternity care midwives providing continuity of care. Yet, large maternal health inequities exist. Māori and Pacific women are over-represented in maternal mortality and morbidity statistics and patient experience is rated poorly by these groups.

Aim: To investigate the barriers to maternal health equity in New Zealand.

Methods: A four-phase research programme, using integrative methodology, began with an integrated review examining the setting for maternal health inequity in New Zealand. Next, the last maternal satisfaction survey (from 2014) was interrogated using structural equation modelling to investigate the influence of different aspects of access on maternal satisfaction. The third and most extensive phase used logistic regression modelling to examine relationships between social determinants of health and severe adverse maternal and perinatal outcomes, using data from the Statistics New Zealand Integrated Data Infrastructure linked administrative datasets from 2003 to 2018. Finally, through a Foucauldian lens, I critically analysed the embedded systems and processes that may enable health inequities to persist and inhibit progress in ameliorating them.

Results: The review found that New Zealand maternal health inequity is situated in a complex context, comprising the unique maternity system and its acceptability, sparse geographic population distribution, neoliberal politics, cultural factors and a colonial history. Structural equation modelling found some groups – especially young women, those in remote rural and/or high socioeconomic deprivation areas – were less satisfied with specific equity and access aspects often associated with poor maternal and perinatal outcomes. In a dataset of over 950,000 births, marked inequities in maternal and perinatal outcomes were found. Once adjusted for demographic variables (socioeconomic deprivation, education, parity, age, rural/urban residence and ethnicity) Māori and Asian women had an adjusted odds ratio of 1.21 (95% confidence interval (CI) 1.18-1.23) and 1.39 (95% CI 1.36-1.43) for poor outcome respectively compared to New Zealand European/European women. Variables indicating lack of engagement with the healthcare system had the highest adjusted odds ratios of adverse maternal and perinatal outcomes. Over 20% of the birthing population in some geographic areas suffered a severe adverse outcome over this 16-year period. Critical analysis demonstrated that women experiencing the poorest outcomes are also often considered ‘outside the norm’. In Foucauldian terms this allows labelling of some groups as aberrant and enables society to tolerate inequities for those considered ‘other’.

Conclusion: This research, using large linked administrative datasets and novel methods (e.g., imputation using predictive mean matching), found maternal health inequity in Aotearoa New Zealand was strongly associated with social determinants, consistent with international evidence. These maternal health inequities continue as affected women are from groups that are marginalised by society. The critical analysis provided insight into systemic changes that are required to eliminate these inequities. At a policy level, urgent attention is needed to change systems to make accessing care safe and acceptable, in both primary and secondary services. And, as a society we must refuse to accept maternal health inequities as inevitable.